This document discusses eyelid reconstruction techniques for both upper and lower eyelids. The goals of eyelid reconstruction are to provide adequate eyelid function, globe protection, and acceptable aesthetic results. Common indications for reconstruction include resection of malignancies in the upper eyelid and trauma in the lower eyelid. Reconstruction techniques range from primary closure for partial thickness defects to flap reconstruction for larger defects. Flap choices depend on the size and location of the defect being reconstructed.

1. UPPER AND LOWER EYE LID
RECONSTRACTION
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2. • THE GOALS OF EYELID RECONSTRUCTION ARE
(1) TO PROVIDE ADEQUATE EYELID FUNCTION.
(2) TO AFFORD GLOBE PROTECTION
(3) TO ACHIEVE ACCEPTABLE AESTHETIC RESULTS
• UPPER EYELID SERVES A MORE IMPORTANT ROLE IN GLOBE PROTECTION BECAUSE IT
COVERS A GREATER AREA OF THE CORNEA.
• COMMON INDICATIONS FOR RECONSTRUCTION IS DUE TO RESECTION OF
MALIGNANCIES IN UPPER EYELID AND TRUMA IN LOWER EYE LID.

3. • PARTIAL-THICKNESS LOSS
-SKIN
LOSS OF SKIN MAY BE CLOSED PRIMARILY OR REPLACED WITH FULL-THICKNESS
SKIN GRAFTS TO PREVENT EXCESSIVE GRAFT CONTRACTION. SKIN FROM THE
CONTRALATERAL LID IS THE BEST SOURCE FOR A THICKNESS MATCH.
ALTERNATIVELY, POSTAURICULAR SKIN MAY BE USED.
TIP: IT IS IMPERATIVE NOT TO CREATE TENSION ON THE LID WITH PRIMARY
CLOSURE, BECAUSE THIS LEADS TO ECTROPION.
-CONJUNCTIVA
CONJUNCTIVA IS BEST REPLACED BY ADVANCEMENT OF AN ADJACENT SLIDING
TRANSCONJUNCTIVAL FLAP. WHEN THIS IS NOT POSSIBLE, GRAFTING IS
NECESSARY. BUCCAL OR NASAL MUCOSA PROVIDES THE REQUIRED DONOR SITE
,NASAL MUCOSA TENDS TO CONTRACT LESS THAN BUCCAL MUCOSA (20% VERSUS
50%). SKIN GRAFTS ARE CONTRAINDICATED, BECAUSE SURFACE CHARACTERISTS
IRRITATE THE CORNEA.GRAFTS OF CONJUNCTIVA ARE SUBJECT TO SIGNIFICANT
CONTRACTION AND SHOULD BE AVOIDED.

4. -TARSUS
LOSS OF TARSAL STRUCTURE USUALLY IS PART OF A COMPOSITE LOSS. IT SHOULD
BE REPAIRED PRIMARILY ,CARTILAGE GRAFTS, OR ACELLULAR DERMAL MATRIX.

5. • FULL-THICKNESS LOSS
UPPER LID
DEFECTS UP TO 25%-30% OF THE LID MAY BE CLOSED PRIMARILY IN OLDER
PATIENTS WITH SIGNIFICANT LAXITY, 40% DEFECTS MAY BE CLOSED PRIMILARLY.
WHEN SIGNIFICANT TENSION IS PRESENT, LATERAL CANTHOTOMY AND CANTHOLYSIS
MAY PROVIDE ADDITIONAL LAXITY FOR CLOSURE.
TIP:PRECISE APPROXIMATION OF TARSAL PLATE IS CRITICAL FOR PROPER LID
“SKELETAL” SUPPORT.

6. FLAP RECONSTRUCTION
DEFECTS BETWEEN 25% TO 75%
• TENZEL SEMICIRCULAR FLAPCOMBINING LATERAL CANTHOTOMY AND
CANTHOLYSIS WITH A LATERALLY BASED MYOCUTANEOUS FLAP ALLOWS
CLOSURE OF DEFECTS OF UP TO 60% OF THE UPPER LID.

7. • LID-SHARING FLAP (MUSTARDE PEDICLED FLAP) USED FOR DEFECTS OF THE
CENTRAL UPPER LIDFLAP DIVIDED ABOUT WEEK 6 AND DONOR SITE CLOSED
PRIMARILY.

8. • DEFECTS OVER 75%
• CUTLER-BEARD FLAP A TWO-STAGE PROCEDURE ENTAILS ADVANCEMENT OF A
FULL-THICKNESS LOWER LID FLAP PASSED BENEATH THE LOWER LID MARGIN
AND SUTURED INTO THE DEFECTLACKS SUPPORT AT THE LID MARGIN AND
REQUIRES CARTILAGE GRAFTING BETWEEN THE CONJUNCTIVA AND MUSCLE
LAYERS,FLAP DIVISION PERFORMED AT 3-6 WEEKS.

9. • TEMPORAL FOREHEAD FLAP (FRICKE FLAP) WHEN ADEQUATE LID TISSUE IS
UNAVAILABLE FOR DONOR TISSUE, TEMPORALLY BASED FLAPS MAY BE
USEFULTISSUE QUALITY IS THICKER AND LESS IDEAL; IT SHOULD BE RESERVED
FOR SPECIAL CIRCUMSTANCES.

10. • LATERAL CANTHAL DEFECTS PRODUCES A ROUNDED LATERAL CANTHUS AND A
SHORTENED PALPEBRAL FISSURE.
SIMPLE DISRUPTION: PRIMARY REPAIR IF BOTH ENDS OF THE LCT ARE PRESENT.
COMPLEX DISRUPTION: CANTHOPLASTY IF LATERAL END OF THE LCT IS ABSENT.
-MEDIAL END PRESENT: SUTURE TO PERIOSTEURN OF LATERAL ORBITAL RIM
-MEDIAL END ABSENT: USE LATERAL TARSAL STRIP OR PERIOSTEAL FLAP
CANTHOPEXY FOR LCT LAXITY-SLIGHT OVERCORRECTION PREVENTS
RECURRENCE.
A LOCAL FLAP, REGIONAL FLAP, OR SKIN GRAFT CAN BE USED FOR SOFT TISSUE
COVERAGE.

11. • MEDIAL CANTHAL DEFECTS RULE OUT INJURY TO THE CANALICULAR SYSTEM.
SIMPLE DISRUPTION: PRIMARY REPAIR IF BOTH ENDS OF THE MCT ARE PRESENT
COMPLEX DISRUPTION: CANTHOPLASTY IF MEDIAL END OF THE MCT IS ABSENT.
*IF AVULSED, MAY REQUIRE TRANSNASAL WIRING (POSTEROSUPERIOR TO THE
POSTERIOR LACRIMAL CREST) TO PREVENT POSTOPERATIVE TELECANTHUS.
CANTHOPEXY FOR MCT LAXITY-SLIGHT OVERCORRECTION PREVENTS
RECURRENCE.
A LOCAL FLAP, REGIONAL FLAP, OR SKIN GRAFT CAN BE USED FOR SOFT TISSUE
COVERAGE.

12. • LOWER LID
DEFECTS OF UP TO 25%-30% OF THE LID MAY BE CLOSED PRIMARILY. IN OLDER
PATIENTS WITH SIGNIFICANT LAXITY, 40% DEFECTS MAY BE CLOSED SIMILARLY.
WHEN SIGNIFICANT TENSION IS PRESENT, LATERAL CANTHOTOMY AND
CANTHOLYSIS MAY PROVIDE ADDITIONAL LAXITY FOR CLOSURE.
FLAP RECONSTRUCTION
DEFECTS BETWEEN 25% TO 75%
• TENZEL SEMICIRCULAR FLAP COMBINE LATERAL CANTHOTOMY AND
CANTHOLYSIS WITH A LATERALLY BASED MYOCUTANEOUS FLAP FOR CLOSURE OF
DEFECTS OF UP TO 60% OF THE UPPER LID ADDITIONAL SUPPORT MAY BE
PROVIDED WITH PERIOSTEAL FLAP, CARTILAGE, OR OTHER HOMOLOGOUS GRAFT.

13. TRIPIER FLAP MYOCUTANEOUS FLAP USED FOR PARTIAL-THICKNESS COVERAGE OF
LOWER LID
ORIGINALLY DESCRIBED AS A BIPEDICLED FLAP; MAY BE BASED ON A SINGLE
PEDICLE
TIP: DEFECTS THAT EXTEND PAST THE PUPIL USUALLY REQUIRE A BIPEDICLED
TECHNIQUE TO PREVENT DISTAL NECROSIS.

14. • DEFECTS OVER 75%
• HUGHES TARSOCONJUNCTIVAL FLAPTWO-STAGE PROCEDURE; TRANSFERS
CONJUNCTIVAL LINING AND A SMALL PORTION OF THE SUPERIOR TARSUS FOR
SUBTOTAL OR TOTAL LOWER LID RECONSTRUCTION. SKIN COVERAGE PROVIDED
BY FLAP OR FTSG; FLAP DIVIDED AT 4-6 WEEKS.

15. • CHEEK ADVANCEMENT FLAP (CLASSIC MUSTARDE)USEFUL FOR TOTAL LOWER LID
RECONSTRUCTION TO PREVENT LID RETRACTION, CRITICAL TO PROVIDE
TENSION-FREE MOBILIZATION OF TISSUE INTO TARGETED SITE AND LATERAL
CANTHAL FIXATION
TIP: ELEVATION OF A THIN FLAP IS HELPFUL.

16. • OTHER EG. MCGREGOR

17. • LOCOREGIONAL FLAPS IF ADEQUATE QUALITY LID TISSUE UNAVAILABLE, USE
REGIONAL SOFT TISSUES IDEAL QUALITY TISSUE NOT PROVIDED BECAUSE OF
THICKNESS

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